QD: News Every Day--Pain's toll warrants new treatment approaches

Pain affects at least 116 million adult Americans annually and costs the nation between $560 billion and $635 billion annually, says a new report from the Institute of Medicine (IoM). Much of this pain is preventable or could be better managed, added the committee that wrote the report.

The breakdown of pain's impact includes the costs of health care ($261-$300 billion) and lost productivity ($297-$336 billion) attributable to pain, according to a press release. These figures do not include lost tax revenues. Medicare bears one-fourth of U.S. medical expenditures for pain, totaling at least $65.3 billion, or 14% of all Medicare costs in 2008. Medicare, Medicaid, the Department of Veterans Affairs, TRICARE, workers' compensation, and other federal and state programs paid out $99 billion in 2008 for pain.

Pain is a chronic disease unto itself, and there is a moral imperative to treating it with a comprehensive, interdisciplinary approach that includes the patient. Chronic pain has a distinct pathology that triggers changes throughout the nervous system that often worsen over time. "It has significant psychological and cognitive correlates and can constitute a serious, separate disease entity," the report reads.

The majority of care and management should take place through primary care providers and patient self-management, with specialty care reserved for more complex cases. Health care organizations should take the lead in developing innovative approaches and materials for patient self-management.

The report acknowledges that opioids crate problems of drug diversion and abuse, even as questions remain about their long-term usefulness. But, "[W]hen opioids are used as prescribed and appropriately monitored, they can be safe and effective, especially for acute, post-operative, and procedural pain, as well as for patients near the end of life who desire more pain relief."

Pain often produces psychological effects, such as anxiety, depression, and anger. While interdisciplinary approaches are the most promising, there are too many barriers to that approach, including reimbursement for clinicians.

As a result, costly procedures often are performed when other actions should be considered, such as prevention, counseling, and facilitation of self-care. Insurers and government health care programs are not designed to efficiently pay for an interdisciplinary approach of integrated patient management. The report calls on Medicare, Medicaid, workers' compensation programs, and private health plans to find ways to cover interdisciplinary pain care.

In addition, adequate pain treatment and follow-up is hampered by uncertain diagnosis and societal stigma, especially when patients do not respond to treatment.

"Understanding chronic pain as a disease means that it requires direct treatment, rather than being sidelined while clinicians attempt to identify some underlying condition that may have caused it," the report reads.

Education should include a "substantial" amount of training. For example, a recent study found that only five of the nation's 133 medical schools have required courses on pain and just 17 offer elective courses. Licensing and certification exams should include assessment of pain-related knowledge and capabilities. Programs that train specialists or offer training in advanced pain care need to be expanded.

The committee called for coordinated, national effort with results expected as soon as the end of 2012 including:--Create a comprehensive population-level strategy for pain prevention, treatment, management and research;--Develop strategies for reducing barriers to pain care; --Support collaboration between pain specialists and primary care clinicians, including referral to pain centers when appropriate; and--Designate a lead institute at the National Institutes of Health responsible for research.

Others efforts should be in place by 2015, including providing educational opportunities in pain assessment and treatment in primary care. ACP Internist reported on prescription opiate abuse and outlined ways internists can intervene, as well as available resources to help them with this patient group.

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